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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SigThe pplication. <br /> r�:07APPLICATION <br /> T� (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h reb made to carry business in the jurisdictional area of th an J aquinLocal Health Diistric r i <br /> N Business Name (DBA) GA247, Address Ank _56714A) <br /> aOwner Address .. <br /> J Firm Partners, Addresses and Telephone Numbers <br /> { <br /> CL <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. 4 [ <br /> L Applicants Name (Print R Title 77; Date r l7� <br /> Please check Applicable Category (1=7)a d Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> CN <br /> I, <br /> No. CAL. License No. CAL. License Renewal No. + <br /> Capacity Gal., Weights-& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name • R.S. or R.C.E. No. <br /> Testa Location " Test Date/Time <br /> 4. a SANITATION PERMIT <br /> Job Address/Loption <br /> Owner A_C_LS Address S 61W-1 <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 21,1'�EEPAGE PIT ❑ PACKAGE PLANT <br /> 1 PERMANENT ❑ TEMPORARY ''❑ NEW '_13-MEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site {� <br /> k <br /> No. of Units Equipment Storage/Cleaning Location(s) sof. 4. ; <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 'v: F <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> hereby certify that I have repared this appli tion and at the work will be done in accordance with San Joaquin County = !_ <br /> ordinances, state laws, a les an gulati of the Jo uin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> t <br /> f <br /> FOR DEPARTMENT USE ONLY f <br /> r v <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> El July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION - BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT X <br /> FEE �`� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> i <br /> OTHER <br /> ' T <br /> Received by - Date Receipt No Permit No. Issuance Date Mailed Delivered - <br /> .� y <br /> APPLICANT—RETURN-ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK70N,CA 8520 <br />